AbstractAim:
This article describes the Adult Step-up Step-down mental health
service that operates in Canberra, Australia, as a short-term sub-acute
residential rehabilitation service. Description: The service accepts
mental health clients who are preparing for discharge from an inpatient
unit, as a transitional service to support them as they prepare to
return to living in the community (step down). The service also accepts
mental health clients living in the community who are experiencing an
escalation in symptoms and a short stay in a residential rehabilitation
program may avoid hospitalization (step up). The service provides 5
beds in an open, home-like environment, with 24 hour staffing,
including clinical support. Conclusion: Step-up step-down services are
increasingly being implemented in Australia to address the service gap
between inpatient and community care, providing a personal and tailored
support base for clients prior to returning to independent living.Keywords: Mental health, Residential service, Community-based, Transitional service, Mental illness.

Introduction:

Residential
mental health services show promise in assisting people suffering from
a mental illness to receive treatment in a less restrictive setting
than psychiatric inpatient units. The Step-up Step-down program is a
sub-acute, short-term, residential mental health service that provides
support and access to treatment in a 24 hour staffed, open home-like
environment. This article describes the program in detail, as an
example of how a step-up, step-down program can be integrated into the
mental health system continuum of care.

Continuum of CareThe
continuum of care of mental health services ranges from community-based
care to psychiatric inpatient units, with jurisdictions differing in
their delivery of mental health services across the service continuum.
At the less restrictive end of mental health services, many mental
health clients live in their own home, with community-based care
provided under the care of a case manager and other mental health
professionals, such as Assertive Community Treatment (Phillips et al.,
2001), which offers a multi-skilled team approach. Community-based care
is often the preferred service option for many clients (Rose, 2001).
For people requiring more direct support during a time of crisis, there
are a range of acute/crisis residential units, some community based
(e.g. Crisis Stabilization Units; Adams & Mallakh, 2009) and others
attached to inpatient units (Slade et al., 2010), that offer short-term
residential support until symptoms have stabilized. Sub-acute
residential services offer longer-term accommodation and support
options and can provide care in a non-hospital environment for people
recovering from an acute episode (Johnson et al., 2009; Sledge et al.,
1996) or transitioning from hospital to the community (Sledge et al.,
1996; Weisman, 1985). At the more restrictive end of the service
continuum are inpatient Mental Health Units, which offer psychiatric
services for mental health clients who have acute symptoms, have
limited support, or are at risk of causing harm to themselves or others
(Horsfall, Cleary & Hunt, 2010).

There is a growing interest
in developing mental health services that are effective in promoting
both recovery and positive psychology approaches, aimed at not only
treating illness but also increasing well-being, within the individual
experience of recovery (Slade, 2010). One key component of mental
health recovery is hope, and research has identified several
hope-fostering strategies that show promise when built into a
recovery-focused program, including: collaborative strategies for
management of the mental illness; developing relationships; peer
support; support for the development and pursuing of realistic goals;
and interventions to increase and support positive factors such as
self-esteem, self-efficacy and well-being (Schrank et al., 2012).
Empowerment, relationships and social inclusion are also important
factors in facilitating recovery outcomes, which require
recovery-oriented services to work within the community and social
systems of the individual (Tew et al., 2012).

Sub-acute Short-term Residential Mental Health ServicesSub-acute,
short-term residential mental health services have been developed to
provide support and accommodation for people with mental illness in a
less restrictive environment than inpatient units, often with a focus
on development of skills necessary for successful community living,
such as budgeting, domestic and interpersonal skills. These services
are designed to provide an alternative to hospital treatment, taking
some of the pressure off inpatient units, and comprising a more
cost-effective delivery of services in a least restrictive environment
(Lloyd-Evans et al., 2009). These services can also offer a
transitional service for patients preparing to return to the community.
Step-up step-down units are increasingly being implemented in the
Australian mental health system as part of system reforms to better
meet the needs of mental health clients. Although the research evidence
is limited, several studies have found sub-acute residential units to
be effective in providing positive clinical outcomes and they appear to
comprise a cost-effective alternative to hospitalization (Thomas &
Rickwood, 2013).

Adult Step-up Step-down ProgramThe
Adult Step-up Step-down program commenced operating in Canberra in the
Australian Capital Territory (ACT) in January 2009. The program is a
partnership between a non-government organisation (Mental Illness
Fellowship Victoria) and ACT public mental health services (ACT Mental
Health, Justice Health and Alcohol and Drug Services (MHJHAD)). The
program operates as a five-bed residential unit for adults, taking
referrals from the inpatient units at two major hospitals for patients
preparing to leave the hospital who would benefit from additional
support before returning to the community (step-down). It also takes
referrals from clinical mental health workers, on behalf of clients
living in the community who are experiencing an escalation in symptoms
(step-up), with the aim of providing support to assist the client to
return to the community, thereby avoiding hospitalization. The service
maintains full occupancy at all times, with clients in the community or
in the inpatient unit selected for admission to the residential
service, ready to enter the program when a vacancy arises.

The
Step-up Step-down service operates under a model of care founded on
principles of recovery and psychosocial rehabilitation. In line with
research into key aspects of recovery, the model promotes hopefulness,
personal empowerment, social connectedness and self-determination in
the recovery process, and global well-being for clients experiencing
major mental illness. The program provides a safe environment where
these elements of recovery can be explored and developed, combined with
evidence-based biological, psychological and social interventions. Key
features of the recovery orientation of the program are a collaborative
decision making approach in the setting of recovery goals, emphasis on
development of social connections, and personal strategies to manage
symptoms and foster positive mental health.

ClientsPeople
who are considered eligible for the program are generally aged between
18 and 64 years, however older clients may be admitted on a
case-by-case basis, if they are identified as potentially benefitting
from the program. (Although there is a need for older people with a
mental illness to be able to access suitable mental health services, in
the Australian health system, mental health clients over the age of 65
are provided with services through the Aged Care system; Dept of Health
and Ageing, 2008). Intake and discharge are administered by MHJHAD in
collaboration with Mental Illness Fellowship staff, after discussion
with the potential client and their case manager. Step-down clients are
currently an inpatient, with symptoms that have been stabilized, and
are preparing to return to living in the community. Step-up clients are
current clients of MHJHAD and generally experiencing early signs of
relapse but do not, or do not yet, meet the criteria for hospital
admission. Pre-entry screening, by the clinical nurse and case manager
with potential clients, is used to determine whether clients have an
attitude of collaboration and participation that will enable them to
achieve recovery goals. The demographic profile of clients in the
program, since the program began, is presented in Table 1.

In
order to provide a safe environment for clients and staff, a risk
assessment is performed as part of the pre-screening eligibility of
clients, with consideration given to risk of self-harm, risk to others,
and risk associated with living in a congregate setting. Risk, in a
shared facility, is multi-facetted and client and staff safety is an
important focus of the service. If there are changes in a client’s
ability to maintain their safety, or risk issues for other clients or
staff develop, then clients may be admitted to the inpatient unit, or
discharged from the residential unit and placed under the direction of
their clinical manager.

StaffingThe program is staffed 24
hours onsite, with day staff including a full-time manager, a mental
health specialist nurse who is either onsite or on-call, and two social
workers; the night is staffed with one staff member with the manager
on-call if needed. The mental health nurse provides clinical support
and is responsible for bed management, medication management, clinical
risk and mental state assessments, secondary consultation, and ongoing
liaison with psychiatrists and case managers. The program employs two
social workers (called key workers), who provide support and training
to clients on an individual basis, including developing a recovery plan
and self-management skills, assisting in developing daily routines,
accompanying clients to appointments and actively helping clients
establish meaningful community connections.

All staff have
training in mental health or social/community work and have an
understanding of mental illness and recovery-oriented care. Staff also
attend in-house training on relevant topics, and conferences and other
training events to continue to improve their knowledge of new
developments in mental health recovery. To maximize recovery outcomes,
clinical and program staff collaborate frequently concerning individual
clients, including updates on recovery plans, client needs, and mental
state changes and risks.Facilities

The residential unit has
two wings, one with three bedrooms and a shared bathroom and the other
with two bedrooms and a shared bathroom. There is a mix of three male
and two female, or two female and three male clients at any time,
allowing for gender separation. A large communal kitchen, dining room
and lounge room are in the centre of the house, opening up onto
enclosed front and rear gardens. A separate sunroom is available, away
from the communal living areas. Bedrooms are equipped with bed, storage
facilities, phone and a TV/DVD. Clients are responsible for maintaining
their room and for cleaning the kitchen and keeping a tidy environment.Program interventions

Clients
enter the program with a range of clinical symptoms and from a variety
of social backgrounds. To best meet the varied needs of clients,
broad-based and flexible interventions are provided, tailored to the
individual’s own needs, with the aim of assisting clients towards
recovery, stabilization of symptoms, and development of skills in
relapse prevention. Program interventions are listed in Table 2.

Table 2Components of Step-up Step down program

Community
meeting

Clients and staff meet weekday
mornings for approximately 20 minutes, to plan the day’s activities, discuss
topics of concern and organise community events.

Psychosocial
group

A staff-facilitated peer
support/educational one-hour session conducted once a week with topics for
discussion chosen by clients, such as sleep patterns, depression, medication,
anxiety, and health and well being. Clients are given an opportunity to share
their experiences and problem solve together.

Optimal Health

The Optimal Health program is a
structured evidence based program (Gilbert et al., 2012) facilitated by a
trained staff member, which provides clients with knowledge about their
illness and supports them to develop personal self-management strategies. The
program is run over four weeks, with the group meeting for one-hour sessions,
two mornings each week.

Art/music
group

A weekly class facilitated by an art
teacher, on various styles of art and music. This program is individually
tailored, with the teacher encouraging clients to explore their interests and
giving support to individual project.

Personal
Engagement

Staff provide one-on-one engagement
and individual support for clients, with a focus on recovery goals, personal
illness management and relapse prevention.

Social

outing

A weekly outing to a local venue
chosen by clients. Popular outings include tourist attractions, museums and
the lake, designed to give clients experience and growing confidence in being
able to access parts of their local community.

Physical
therapies

Clients are encouraged to participate
in exercise programs at a level at which they feel comfortable, with options including
daily walks with a key worker, using the available push bikes, or joining a
local sport or exercise group.

Focused
rehabilitation

Key workers provide support to
facilitate rehabilitation and preparation to return to the community,
including assistance with budgeting, learning to
use public transport, shopping, developing a relationship with a local
pharmacist, job and housing applications, and assistance with government
departments.

Daily living activities

Clients
are offered support and guidance in the development of basic life skills,
such as meal planning, shopping, cooking, cleaning, and personal hygiene.

Communal meal

Clients
and staff share an evening communal meal twice a week. Clients are supported
to develop skills in meal planning, shopping, food preparation and cleaning
up after the meal. The shared meal operates as a social experience for
clients and assists in the development of a community atmosphere.

Community linkage

Clients
are encouraged to form connections with community groups with whom they share
common interests, and other community services that will provide resources
and support; staff are available to help establish these connections.

Family support

Family
members and carers are welcome in the program and clients are encouraged to
maintain family and friendship connections. Family members are offered
support, psychoeducation resources, and referrals to community support.

Alcohol or other drug (AOD) counseling

Staff
are trained in AOD interventions and provide support to clients in this area.
Clients with substance use problems are referred to suitable residential or
community support services both during and as they transition from the
program.

Transition planTransition
planning is incorporated into each client’s support plan during the
first week of entry, with clients and staff setting goals that clients
hope to achieve during their time in the program. The locus of
responsibility for treatment moves from the treating team to the client
as the client progresses in the program towards exit. In addition to
management of clinical symptoms, aspects of the client’s daily
functioning are also considered as the transition date approaches, so
that clients are able to self-manage their medications, domestic
skills, daily routine and appointments. It is the goal of the service
that at the time of exit clients will show clinical improvements, be
well-engaged with appropriate ongoing clinical and psychosocial
supports, and progressing the goals in their recovery plan.

However,
at times a client may experience an escalation in symptoms while in the
program and this is managed by all clients remaining clients of MHJHAD,
which ensures immediate access to the public mental health community
treatment team or readmission to an inpatient unit in the event of a
crisis.

Pathways of careStep-up and step-down
clients participate in the same daily activities, however, there are
differences in the nature and goals of the service for these two client
groups. The goal of treatment for step-up clients is to stabilize their
symptoms and reduce the length of untreated psychosis in, what is seen
by some clients, a less stigmatizing environment than hospital. A
recovery plan is developed with clients, with clear recovery goals and
transitional steps to return to their usual place of living, and
appropriate connections made to provide ongoing support in the
community.

For example, a female client in her early 30’s had
previously been admitted to the Step-up Step-down program after leaving
the inpatient unit. Several months later she began to experience an
escalation in psychotic symptoms, which on previous occasions had
resulted in her being hospitalized, causing her considerable stress and
disruption to the stable life she was trying to build for herself.
Admission into the Step-up Step-down program allowed her to have 24
hour support while her symptoms were stabilized. Staff had previously
assisted the client in obtaining supported employment, and she was able
to maintain connections with her place of employment and continued to
work occasional shifts. After a five week stay in the program, her
clinical symptoms had improved and she felt ready to return home,
receiving four weeks of outreach support to assist her to continue with
her recovery goals while back at her home.

The goals for
step-down participants tend to be more practical and functional, with a
focus on preparing clients to return to the community after an extended
stay in the inpatient unit. Although these clients’ symptoms are
settling, they may not have achieved a level of functional recovery
adequate for return to their usual living arrangements. For some
clients, such as those with first episode psychosis, their stay in the
inpatient unit may be shortened because of the opportunity to transfer
to the residential unit for ongoing clinical observation and support.
Key workers ensure that step-down clients are given support in taking
on daily living tasks, such as personal hygiene, cooking and cleaning,
and that connections with community support systems are established.
Where possible, clients are encouraged as their exit date approaches,
to sleep overnight at their own home and return to Step-up Step-down
during the day, allowing clients to experience gradual gains in their
confidence and their ability to cope with living in the community
again. For example, a client suffering from major depressive
disorder had been an inpatient for several months, and as part of his
continuation of care was offered the opportunity to stay at Step-up
Step-down. The client’s symptoms were stable, however, he and his
treating psychiatrist had concerns about him returning home as he had
lived in a socially isolated area and there were concerns that his
symptoms may worsen if he returned to a lifestyle with social
isolation. The client stayed at Step-up Step-down for six weeks and was
encouraged to develop daily routines of getting up at the same time,
taking medications, attending morning meetings and activities, and
participating in combined cooking events. Staff assisted the client to
find new accommodation and supported his transition into his new home
with outreach support and assistance developing community connections.

Cost effectivenessIn
terms of cost effectiveness, the cost per day per client in the Step-up
Step-down program is $517, compared to the average cost per client per
day of $758 in public psychiatric hospitals in Australia (Australian
Institute of Health and Welfare, 2011). Although there are daily cost
savings delivered through the residential unit, there are community
health costs that are not included in this, such as the continued
clinical management and specialist support through the community mental
health system. The treatment environments are also different, with
inpatients provided with on-site medical and psychiatric care and
therapy, services that are not provided on-site at the residential
unit. The Step-up Step-down program operates at a cost higher than the
residential service national average of $324 per day (Australian
Institute of Health and Welfare, 2011) primarily because it provides 24
hour staffing, including two full-time social workers, a level of staff
support higher than some other types of residential services. Although
the cost savings are minimal, when the community health support costs
and differences in treatment are considered, the sub-acute residential
service does free up beds in the inpatient unit for patients with more
serious mental health needs, offering a cost-effective alternative to
the inpatient unit for some mental health clients. The Step-up
Step-down program currently has five beds, and in addition to this a
youth Step-up Step-down service opened in 2013, which provides an
additional six beds for young adults aged between 18 and 25 years with
mental health problems, to help meet demand for beds in alternative
residential services.What can be learned from the Step-up Step-down model?Within
the mental health continuum of care there is a range of services
meeting different needs for safety, treatment, support, and advocacy
across the many different types of individuals requiring mental health
treatment. In Australia, there is an emerging trend to provide clients
with residential treatment alternatives that can meet clients where
they are at, either preparing to return home after a stay in hospital,
or becoming unwell and wanting to avoid hospitalization. The
residential unit is well suited to offering both the functional skills,
capabilities and personal support systems tailored to the needs of
inpatients leaving hospital in their transition back home, and also
assisting clients who are becoming unwell to manage their symptoms,
with the aim of avoiding hospitalization and returning to independent
living. The Step-up Step-down model promotes both recovery and positive
psychology approaches and offers an alternative to hospital, allowing
some mental health clients a choice of services on the service
continuum.

Strengths and limitations of this modelThe
Step-up Step-down model provides an individually tailored support
service to clients, with peer support and the opportunity for clients
to make social connections and to connect with relevant community
services. Length of stay is fairly flexible, and a client’s stay can be
extended if this will assist the client in making further gains in
their recovery goals (although generally not beyond three months).
However, there are limitations to the service. It is a small
residential unit and if a client finds they are not fitting in to the
environment, due to problems with a staff member or another client,
then their stay in the program and the likely benefits they could
receive are disrupted, perhaps by an early exit from the service. At
times, the maximum length of stay is a limitation, as it can be
difficult for people with a mental illness to find appropriate
long-term accommodation, particularly in a supported setting if this is
needed, and they may have benefitted from a longer stay at Step-up
Step-down prior to re-settling in the community.

ConclusionThe
Adult Step-up Step-down program provides both a transition service for
inpatients preparing to return to the community and early intervention
for people with mental illness living in the community. The service
provides staff support, psychosocial, art and physical activity
programs, and enables clients to establish links with external
community programs. Further research is required to determine the
effectiveness and value of such a service approach for clients, their
families and the community, as community-based residential step-up
step-down services potentially fill an important gap in a comprehensive
mental health service continuum.